Latest news with #DiscoveryHealth
Daily Maverick
5 hours ago
- Health
- Daily Maverick
Beat the mid-year medical blues
There are ways to help manage your costs after your medical savings account is depleted. We're into the second half of the year and you may be one of thousands of medical scheme members now finding your medical savings accounts are depleted, leaving you to pay directly for day-to-day costs. According to the Council for Medical Schemes 2022/23 annual report, South Africans paid close to R40-billion out of pocket for healthcare, with nearly half of this going towards outpatient services, not hospital stays. These costs include essential visits to specialists, radiologists and dentists, which are often not fully covered once medical savings accounts are exhausted. Although there is no magic fix, there are ways to change the way you access healthcare to make it more affordable. For example, Tania Joffe, founder of Unu Health, says that instead of spending R500 or more on a face-to-face GP visit, you could opt to speak to a doctor for a fraction of that cost through a telemedicine app. 'The old model of always visiting your GP or specialist in person for everything just isn't sustainable any more,' says Joffe. 'It's time to embrace the hybrid model that includes telemedicine.' See more: How medical schemes are using AI's predictive power to revolutionise health risk management One of the easiest ways to reduce medical costs is by taking advantage of low-cost or free screening tools offered by your medical scheme. For example, Discovery Health launched a Personal Health Pathways programme earlier this year. Accessible via the Discovery Health app, the platform helps members and their healthcare practitioners to navigate the healthcare system with precise and personalised healthcare recommendations, improving both immediate and long-term health outcomes for each member. Each pathway is tailored to the member's specific health status, risk profile and engagement patterns, dynamically adjusting as new health data becomes available. Dr Ron Whelan, chief executive of Discovery Health, says the AI-powered platform behind Personal Health Pathways processes more than 33 terabytes of data, and an additional 500 gigabytes are ingested daily. To illustrate the platform's scale, there are more than 7 million possible pathways for completing 12 health actions. Examples of personalised pathway prompts include: A healthy 42-year-old woman may be encouraged to schedule a health check, complete a mental wellbeing assessment, go for a dental check-up, get a mammogram or Pap smear, nominate a primary care GP, complete a Vitality Age Assessment or receive a flu vaccine; A 45-year-old man with elevated cholesterol and blood pressure may be guided to visit his GP for a check-up, collect prescribed medicine, monitor blood pressure or cholesterol levels, or go for prostate or colon cancer screening; and A 65-year-old man who has diabetes may be prompted through the app to schedule an HbA1c test, collect medicine, undergo foot and retinal screenings, complete a prostate cancer test or have a mental wellbeing assessment. When you go to your local pharmacy for medication, ask the pharmacist for the cheapest generic option. When you buy milk, you consider different brands and weigh up the costs before you buy – your medication deserves the same consideration. Tax benefits Continue submitting claims to your medical scheme even though your medical savings account is depleted. The scheme will not pay these claims, but it records the amounts as your out-of-pocket expenditure and this information is shared with the South African Revenue Service. In the long run, this means less admin for you when you submit your tax return and a potential tax benefit – the additional medical expenses tax credit. According to TaxTim, out-of-pocket expenditure that could fall under additional medical tax credits includes: A consultation and medicines supplied by a registered medical practitioner, dentist, optometrist, homeopath, naturopath, osteopath, herbalist, physiotherapist, chiropractor or orthopaedist to you or any of your dependants; The costs of a nursing home or hospital, or any duly registered or enrolled nurse, midwife or nursing assistant (or to any nursing agency in respect of the services of such a nurse, midwife or nursing assistant); Medicines prescribed by a registered medical practitioner and acquired from a pharmacist. Note – this will not include over-the-counter medication such as cough syrup and pain relievers; and Medical expenses incurred and paid outside South Africa. DM
IOL News
7 days ago
- Health
- IOL News
Health bodies urge implementation of report on racial bias in medical aid schemes
The fight for fair treatment of healthcare providers is far from over. Image: File Several years in the making, the fight for justice in South Africa's healthcare sector is far from over. Health bodies say the real test now lies in the implementation of key recommendations from a landmark report, which found that black healthcare providers were unfairly targeted by medical schemes often having their claims withheld based on race and ethnicity. Health Minister Aaron Motsoaledi received the final report from the Section 59 Investigation Panel on Monday. The investigation, commissioned in 2019, examined allegations of racial discrimination and procedural unfairness in the application of Fraud, Waste and Abuse (FWA) processes by major schemes and administrators, including Discovery Health, Medscheme, the Government Employees Medical Scheme (GEMS). Covering the period from 2012 to 2019, the Panel reviewed statistical and testimonial evidence and found that black providers were disproportionately flagged, audited, or penalised through opaque FWA systems. The report also detailed serious procedural shortcomings. These include failure to notify providers of alleged irregularities within a reasonable timeframe, audits that stretch back more than three years, the use of non-transparent algorithms and risk-rating tools, and the absence of independent mediation or effective appeal mechanisms. National Health Care Professionals Association (NHCPA) chairperson Dr Donald Gumede, who was among the complainants in the matter, welcomed the release of the report. 'We are very excited that the final report has finally come to light,' said Gumede. 'What's critical now is the implementation because the report, at the end of the day, is just a document with recommendations. It's what happens next that matters.' He welcomed the proposal for a tribunal, saying: 'There needs to be a proper system in place to regulate the entire healthcare chain. Right now, medical aid schemes operate like a law unto themselves. They are not accountable to anyone and they've destroyed many lives.' Gumede added that they still receive complaints from healthcare professionals and acknowledged that reaching this point had been no easy feat. The South African Medical Association (Sama) welcomed the release of the long-awaited final report and said it had been an active participant throughout the inquiry process. 'The Report validates what many of our members have endured for years: racially skewed targeting, opaque algorithms, and Kafkaesque audit processes,' said Sama chairperson, Dr Mvuyisi Mzukwa. 'Sama has zero tolerance for any form of racial discrimination. Our members have a right to fair treatment, regardless of their race, and patients deserve a health system built on equity and accountability. We urge all medical schemes to act decisively and transparently. South Africa cannot tolerate discrimination masquerading as fraud control. Sama stands ready to work with all stakeholders to restore fairness, trust and accountability in our healthcare financing system.' Sama said they supported the panel's call for urgent remedial action; legislative, regulatory, and operational, to eliminate discrimination and ensure fairness. 'The association has called on the Council for Medical Schemes (CMS) to publish an implementation roadmap within 60 days; on medical schemes and administrators to institute a moratorium on recoveries for claims older than three years until updated rules are adopted; and on the National Department of Health to accelerate long-overdue amendments to the Medical Schemes Act that would require algorithmic transparency and the establishment of independent dispute-resolution mechanisms.' Discovery, Medscheme and the CMS did not respond to requests for comment by deadline. Cape Times
eNCA
09-07-2025
- Health
- eNCA
Discovery Health denies discrimination following Section59 report
JOHANNESBURG - Discovery Health has questioned the Section 59 inquiry released on Monday. In its reaction, the medical aid scheme's CEO, Dr Ron Whelan, denied any form of discrimination and that the findings were flawed in methodology. "Discovery has no way of identifying race of members or providers. We work exclusively on a numbering system," Whelan says. Section 59 inquiry found that medical aid schemes have acted unfairly and in a racially discriminatory manner towards black healthcare providers. This inquiry stems from complaints dating back to 2019. Members of the National Health Care Professionals Association (NHCPA) and Solutionist Thinkers, made public allegations that they were being discriminated against by medical schemes. Additionally, they alleged that their claims were being withheld based on their race and ethnicity. The affected parties appealed to the Minister of Health for intervention. Whelan, however, insists that processes are compliant and ethical. Meanwhile, health professionals who complained that they were being treated unfairly have been vindicated. Among those who welcomed the report was the Solutionist Thinkers Group which represented over 200 doctors in this probe. The group's chairperson, Nomaefese Gatsheni, says they are thrilled by the results but ashamed of those who have rejected the report.
News24
08-06-2025
- Health
- News24
Who pays my medical expenses when I am in a road accident?
The lengthy, ongoing legal battle between Discovery Health and the Road Accident Fund (RAF) may leave you wondering who is liable for your medical costs if you are injured in a motor vehicle accident. The Discovery Health case is confusing and unresolved, but in the meantime, the courts continue to issue judgments ordering the RAF to pay medical scheme members' medical bills. Where does this leave you if you are a medical scheme member injured in a motor vehicle accident? The court cases highlight that the RAF is legally liable for your medical costs, and potentially lost income, when you are injured in a motor vehicle accident and unable to work. However, as a scheme member you are also entitled to claim from your scheme and your scheme is most likely to pay your immediate costs and ensure you are admitted to a private hospital. Schemes pay medical expenses immediately Jaco Rupping, COO of Short-Term Insurance at ASI Insure, says medical schemes are often the first line of financial support for individuals injured in vehicle accidents. 'Your medical scheme will cover immediate and ongoing medical treatment or care, for instance hospitalisation, surgery, and rehabilitation,' he says. The RAF is an after-the-fact insurer, as it takes longer to claim, Rupping says. 'Medical schemes will step in to ensure that treatment is not delayed due to funding concerns,' he says, while cases before the courts prove that RAF claims can take a long time Dr Ron Whelan, chief executive officer of Discovery Health, says that your medical scheme will generally cover the cost of medical care associated with road accidents, particularly where this is an emergency. Schemes are obliged in terms of the Medical Schemes Act to cover all medical emergencies and a number of other listed serious conditions as prescribed minimum benefits (PMBs). Many scheme options also cover you for private hospital admissions. What is the RAF and what does it do? The RAF is a South African state-supported fund that provides compensation to victims of road accidents. It is a form of compulsory social insurance funded by a fuel levy that everyone who puts petrol or diesel into their vehicles pays. The amount of the levy used to fund the RAF is determined annually in the National Budget. In the 2023/24 fiscal year, it was 218c a litre. Last year, almost 80 000 claims were filed and just over 63 000 were finalised. However, the RAF admits that it hasn't resolved all claims dating back several years. It says 90 percent of these have not been paid as a result of inadequate paperwork, which it is attempting to resolve. In addition, the fund has massive liabilities amounting to hundreds of millions of rands and recently lost a court battle with the attorney general to restate its liabilities to a fraction of this amount. In an effort to fix the fund's problems, more proposals have been put forward to limit claims from foreigners and wealthy individuals. What will the RAF pay? The RAF's fact sheet lists the costs for which it will pay, or reimburse, claimants as long as they are not responsible for the accident: Medical expenses, which include emergency and non-emergency medical treatment, only in cases where the expenses have not been paid by your medical scheme; Past and future loss of earnings or income; Future medical expenses; General damages for serious injuries; Direct funeral expenses (excluding aspects such as catering); Past and future loss of support; and, Home modifications and caregivers if needed. Recent court rulings show that if you are in any way to blame for your accident, the RAF will not pay all your costs. Why are Discovery and the RAF arguing over medical costs? In one of the RAF's recent attempts to limit its liabilities, it directed its staff in 2022 not to pay the medical claims of medical scheme members whose schemes had paid their medical bills. Discovery Health succeeded in having this directive declared unlawful in 2023. The RAF then issued a new directive to its employees not to pay medical costs that schemes are obliged to pay as prescribed minimum benefits (PMBs) or emergency medical conditions. Discovery Health challenged this directive as being in contempt of the court order made against the first directive, but two out of three High Court judges ruled against the medical scheme administrator and the challenge was dismissed. Discovery Health has been granted the right to appeal the judgment, and the appeal has yet to be heard. Despite this, in January this year, the RAF was ordered to pay medical costs incurred by Rahldeyah Esack to his estate even though Esack's medical expenses relating to an accident in 2015 were paid by Discovery Health Medical Scheme. Most recently, in March, the RAF was ordered to pay the medical costs of John Moss, a cyclist and medical scheme member who was hit by a vehicle in 2017. The scheme's view Whelan said Discovery Health went to court to stop both the RAF and the Minister of Transport from implementing these directives not only on behalf of the schemes it administers, but also 'in the interests of all medical scheme members in South Africa'. 'Discovery Health's firm contention is that medical scheme members' valid road accident-related medical claims must be processed and paid by the RAF, on the same basis as for any other eligible claimant – as has been the case for the past eighty years,' Whelan says. Whelan said there are two reasons why some medical schemes, such as Discovery Health Medical Scheme, want members to claim medical costs from the RAF and repay the scheme: It ensures that individuals do not benefit from being refunded for medical expenses which they did not actually pay in the first place. The cost of medical schemes is kept as low as possible. Model rules published by the Council for Medical Schemes mean that expenses that can be recovered from other parties are not paid for by the scheme. 'Where these medical claims, which have been paid by the medical scheme, are settled by the RAF, they are refunded to the medical scheme. This protects members from higher medical scheme contribution increases,' Whelan says. Some medical schemes have taken a different approach. The Government Employees Medical Scheme, for example, does not expect members to claim accident-related medical expenses from the RAF. Are scheme members expected to claim from the RAF? Whelan said that, as the process of claiming back from the RAF can take between four and five years on average, Discovery helps members claim these costs back from the RAF. He provided the following bullet-pointed explainer: In terms of the registered rules of the Discovery Health Medical Scheme, members who have lodged a claim against the RAF must: Inform the scheme of such claim; Include the scheme's accident-related medical expenses in the claim against the RAF; Promptly reimburse the scheme with any payment made by the RAF in respect of accident-related medical expenses which were paid by the Scheme; and Inform the scheme of any undertaking made by the RAF in respect of future accident-related medical expenses. KEEP THIS IN MIND Claims against the Road Accident Fund (RAF) can take long and may not cover all your losses, especially income-related losses or non-medical expenses, so it is best to have additional cover to protect yourself, Jaco Rupping, COO of Short-Term Insurance at ASI Insure, says. Also the fund will not pay claims, or not pay them in full, if you were to blame for the accident. Rupping suggests you consider: Disability insurance that pays a lump sum or income if you're permanently disabled; Income protection that covers your loss of earnings if you cannot work either permanently or temporarily; Life insurance that provides for your dependants in the event of death; Severe illness insurance that pays you a lump sum if you are diagnosed with a serious condition; Gap cover insurance that pays shortfalls in medical scheme cover for doctors who treat you in hospital; and, Personal accident cover that pays out a lump sum for injuries, regardless of fault. 'RAF is helpful but not a replacement for these kinds of cover as it is often delayed, partial, and limited,' Rupping says.
TimesLIVE
27-05-2025
- Health
- TimesLIVE
Why most people in SA can't get the shingles vaccine
The only shingles vaccine on the market in SA was discontinued last year. A newer and better vaccine is being used in some countries, but has not yet been registered in SA, though it can be obtained by those with money who are willing to jump through hoops. Shingles is a common and painful condition that mostly affects the elderly and people with weakened immune systems. It generally appears with a telltale red rash and cluster of red blisters on one side of the body, often in a band-like pattern. 'Shingles is pretty awful to get. It's extremely painful, and some people can suffer strokes, vision loss, deafness and other horrible manifestations as complications,' said infectious disease specialist Prof Jeremy Nel. 'Shingles is something to avoid, if at all possible,' he said. One way to prevent the viral infection is by getting vaccinated against it. However, while two vaccines against shingles have been developed and broadly used in the developed world, neither of these are available in SA. Zostavax, from the pharmaceutical company MSD, was the first vaccine introduced to prevent shingles. It was approved for use in the US in 2006 and in SA in 2011. It is 51% effective against shingles in adults over 60. Shingrix is not covered [by Discovery Health] as it is unregistered in SA and is therefore considered to be a general scheme exclusion Dr Noluthando Nematswerani, chief clinical officer at Discovery Health A more effective vaccine, Shingrix, which is more than 90% effective in preventing shingles, was introduced by GlaxoSmithKline (GSK) in the US in 2016. It is not yet authorised for use in SA, but GSK has submitted paperwork for approval with the SA Health Products Regulatory Authority (Sahpra), said company spokesperson Kamil Saytkulov. The superior protection offered by Shingrix compared to Zostavax quickly made it the dominant shingles vaccine on the market. As a result, MSD discontinued the production and marketing of Zostavax. MSD spokesperson Cheryl Reddy said Zostavax was discontinued globally in March 2024. Before then, the vaccine was sold in the private healthcare system for about R2,300, but it was never widely available in government clinics and hospitals. No registered and available vaccine Since Zostavax has been discontinued and Shingrix remains unregistered, the only way to access a vaccine against shingles is by going through the onerous process of applying to Sahpra for a section 21 authorisation, a legal mechanism that allows the importation of unregistered medicines when there is an unmet medical need. 'Access will only be available to those who are able to get section 21 approval' and 'this is a costly and time-consuming process requiring motivation by a doctor,' said Dr Leon Geffen, director of the Samson Institute For Ageing Research. The cost of the two-dose Shingrix vaccine imported through section 21 authorisation is about R15,600, said Dr Albie de Frey, CEO of the Travel Doctor Corporation. People who do go through the effort of getting section 21 authorisation typically have to pay the price themselves. 'Shingrix is not covered [by Discovery Health] as it is unregistered in SA and is therefore considered to be a general scheme exclusion,' Dr Noluthando Nematswerani, chief clinical officer at Discovery Health, told Spotlight. The department of health did not respond to queries regarding whether section 21 processes are being pursued for priority patients in the public sector or whether there has been any engagement with GSK regarding the price of the product. People who receive organ transplants, for example, should be prioritised to receive the shingles vaccine as the medications they are given to suppress their immune systems puts them at high risk of developing shingles. Unlike SA, where companies must sell pharmaceutical products at a single, transparent price in the private sector, the US has no such requirement. Even so, the US Centers for Disease Control and Prevention (CDC) pays $250 (R4,473) for the two-dose Shingrix vaccine through CDC contracts. This is less than a third of the price charged when Shingrix is imported into SA. Equity Pharmaceuticals, based in Centurion in Gauteng, is importing GSK's Shingrix for patients who receive section 21 authorisations to use the unregistered vaccine. It is unclear what price Equity Pharmaceuticals is paying GSK for Shingrix to be imported under section 21 approvals, or what is Equity Pharmaceuticals' mark up on the medicine. When asked about the price of Shingrix, Saytkulov said: 'Equity Pharmaceuticals is not affiliated with GSK nor is it a business partner or agent of GSK. Therefore, we cannot provide any comments with regards to pricing of a non-licensed product which has been authorised for importation through section 21.' Equity Pharmaceuticals also said it was difficult to comment on the price. 'The price of a section 21 product depends on a number of fair considerations, including the forex rate, the quantity, transportation requirements and country of importation. Once the price and lead time are defined for an order, the information is shared with the healthcare provider to discuss with their patient and the medical aid,' the company's spokesperson Carel Bouwer told Spotlight. Nematswerani said 'section 21 pricing is not regulated' and prices can change due to many factors including supplier costs, product availability and inflation. Shingles is caused by the same highly infectious virus that causes chickenpox. Most people are infected with the varicella-zoster virus (VZV) during childhood. Chickenpox occurs when a person is first infected by VZV. When a person recovers from chickenpox, the VZV virus remains dormant in their body but can reactivate later in life as one's immune system weakens. The secondary infection that occurs, typically in old age when the dormant virus reactivates, is called shingles. People who were naturally infected with chickenpox, and those vaccinated against chickenpox with a vaccine containing a weakened form of the VZV virus, can get shingles later in life. However, people who were vaccinated against chickenpox have a significantly lower risk of developing shingles later in life compared to those who naturally contracted chickenpox, according to the World Health Organization (WHO). The chickenpox vaccine is available in the private sector but is not provided in the public sector as part of government's expanded programme on immunisation. Chickenpox is usually mild in most children, but those with weakened immune systems at risk of severe or complicated chickenpox should be vaccinated against it, said Prof James Nuttall, a paediatric infectious diseases sub-specialist at the Red Cross War Memorial Children's Hospital and the University of Cape Town. Who should be vaccinated against shingles? SA does not have guidelines regarding who should receive the shingles vaccine and when they should receive it. The US CDC recommends all adults older than 50 receive the two-dose Shingrix vaccine. They also recommend people whose immune systems can't defend their body as effectively as it should, such as those living with HIV, should get the vaccine starting from age 19. While Shingrix works better than Zostavax to prevent shingles, it has other advantages that make it a safer and better option for people with weak immune systems. The Zostavax vaccine contains a weakened live form of the VZV virus and thus poses a risk of complications in people with severely weakened immune systems. 'In the profoundly immunosuppressed, the immune system might not control the replication of the weakened virus,' explained Nel. The Shingrix vaccine does not contain any live virus and therefore does not present the risk. In March this year, the WHO recommended countries where shingles is an important public health problem consider the two-dose shingles vaccine for older adults and people with chronic conditions. 'The vaccine is highly effective and licensed for adults age 50 years and older, even if they've had shingles before,' according to the WHO. It advised countries to look at how much the vaccine costs compared to the benefits before deciding to use it. The cost of not vaccinating against shingles is high for people who develop the condition, and the health system. 'The risk of getting shingles in your lifetime is about 20 to 30%. By the age of 80 years the prevalence is almost 50%,' said Geffen. 'Shingles is often a painful debilitating condition, with significant morbidity. It can result in chronic debilitating pain which affects sleep, mood and overall function,' he said. Beyond preventing shingles and its complications, new evidence suggests getting the shingles vaccine may also reduce one's risk of developing dementia and heart disease. In April, a large Welsh study published in Nature reported people who got the Zostavax vaccine against shingles were 20% less likely to develop dementia seven years after receiving the vaccine compared to those who were not vaccinated. In May, a South Korean study published in the European Heart Journal reported people vaccinated against shingles had a 23% lower risk of cardiovascular events, such as strokes and heart disease, for up to eight years after vaccination.
